B. Joelsson

Symptoms and Endoscopic Findings in the Diagnosis of Gastroesophageal Reflux Disease

Two hundred and twenty patients with symptoms suggestive of pathologic gastroesophageal reflux were investigated to elucidate the ability of symptoms and endoscopic findings in establishing a diagnosis of reflux disease as measured by ambulatory 24-h pH-monitoring. Daily occurrence of heartburn or acid regurgitation had positive predictive values of 59% and 66%, respectively. pH-monitoring showed pathologic reflux in 75% of patients with esophageal mucosal erosions. Endoscopic erythema of the distal esophagus predicted reflux disease in only 53%. Symptom registration during ambulatory 24-h pH-monitoring showed that about half of the symptomatic events reported by patients with pathologic reflux occurred within 5 min of a reflux episode. The corresponding figure for patients with normal pH-monitoring was less than 20%. We conclude that it is difficult to establish a diagnosis of gastroesophageal reflux disease by patient history alone, that erythema at endoscopy correlates poorly with pathologic reflux, and that reflux disease may be present even with normal endoscopy findings.

Evaluation of Splenic Embolization in Patients with Portal Hypertension and Hypersplenism

Twenty-five patients with hypersplenism caused by portal hypertension were treated by repeated partial splenic embolization. Fourteen surviving patients were followed for up to six years showing a good response on peripheral blood count and bleeding tendency. Three patients died in connection with the treatment and another eight died within half a year because of the underlying liver disease. The discomfort and complications of fever, pain, pleural effusion, and abscess formation and the possibility to avoid these by repeated partial embolization under antibiotic cover are discussed. The results are compared with reports in the reviewed actual literature and the splenic embolization is given a place among the means of a successful selective symptomatic treatment of partial hypertension.

Obliteration of esophageal varices by PTP: a follow-up of 43 patients.

The percutaneous transhepatic portal vein catheterization (PTP) with selective obliteration of the coronary vein and/or the short gastric veins in treating bleeding esophageal varices was introduced in 1974. In order to prevent recanalization of the vessels Buerylate® (isobutyl-2-cyano-acrylate) has been used in 43 patients 55 times during a period of 34 months (October 1975 to July 1978). The obliterative treatment was followed by rebleeding in 35% of the cases and continued bleeding occurred in two patients. Fourteen patients were treated on 16 occasions during acute bleedings, and five of these (36%) died within two months from a portal vein thrombosis caused by the obliterative procedure. Because of these findings PTP with obliteration of the veins feeding the esophageal varices is not recommended as an elective way of treatment. It should only be used in the acute bleeding patient when transesophageal sclerosering therapy, continuous vasopressin infusion and balloon tamponade have failed. Fifty-six per cent of the patients acutely treated stopped bleeding for more than one week, thus avoiding an emergency shunt or devascularization operation which are associated with a high mortality rate.

Bile Salts in the Esophagus of Patients with Esophagitis

It is controversial whether bile salts are important in the pathogenesis of esophagitis. By sampling esophageal contents during ambulatory 24-h pH-monitoring we found that in a group of 18 patients with esophagitis all but 1 had detectable concentrations of bile salts in their esophagus. The concentrations of bile salts were low, however, and similar to those found in the gastric juice of 10 normal controls. It is concluded that bile salts are present in the esophagus of patients with esophagitis and that their presence results from duodenogastric reflux. The role of these refluxed bile salts in the pathogenesis of esophagitis is, however, unclear.

The time pattern of gastroesophageal reflux.

The variations in gastroesophageal reflux over 24 h were analyzed in 220 patients with symptoms suggestive of gastroesophageal reflux disease and in 50 normal subjects by studying the results obtained by ambulatory 24-h esophageal pH-monitoring. Three time periods, differing in amount of reflux, were identified: daytime (0700-1700 h), evening (1700-2400 h), and night (2400-0700 h). The greatest amount of reflux was seen during the evening period. This pattern was not solely due to increase in reflux postprandially, since it persisted even after the elimination of postprandial reflux. The pattern was most pronounced in patients with esophagitis. The pressure of the distal esophageal high-pressure zone was measured at 0800 h, at noon, and at 1600 h during one day in another 10 patients. The pressure was significantly lower at 1600 h than at 0800 h and at noon, providing a possible explanation for the changes seen in gastroesophageal reflux. We have described a time pattern of gastroesophageal reflux that has important implications for the design of medical therapy in different groups of patients.

Portal-Systemic Encephalopathy: Influence of Shunt Surgery and Relations to Serum Amino Acids

Fifty patients with liver cirrhosis, portal hypertension, and a history of bleeding oesophageal varices underwent 15 different cognitive psychometric tests to evaluate the presence of subclinical portal-systemic encephalopathy. None of the patients were clinically encephalopathic. The patients were compared with 50 healthy control subjects. Twenty-three patients showed definite signs of encephalopathy in the psychometric tests, 17 were normal, and 10 were borderline cases. The most pronounced abnormalities were seen in tests reflecting logic inductive capacity, visual spatial performance, cognitive flexibility, perceptual speed, spatial perceptive ability, and psychomotor performance. Tests reflecting word memory were less affected. Serum liver function tests did not differ between patients with deranged and normal brain functions. The serum isoleucine concentration was, however, significantly lower in the encephalopathic patients. The psychometric test results did not differ between patients with alcoholic and nonalcoholic liver cirrhosis, and no change was noted 2 years after shunt surgery.

Pattern of Serum Amino Acids in Patients with Liver Cirrhosis: Influence of Shunt Surgery and Transesophageal Sclerotherapy

The serum amino acid pattern was studied in 30 patients with alcoholic liver cirrhosis, in 15 patients with non-alcoholic cirrhosis, and in nine healthy controls. Patients with alcoholic liver cirrhosis had significantly increased serum levels of aspartic acid, proline, methionine, tyrosine, phenylalanine, and tryptophan compared with controls. Valine was significantly decreased. Patients with non-alcoholic liver cirrhosis differed from patients with alcoholic liver cirrhosis only in having significantly greater serum levels of glycine. The serum amino acid pattern of nine cirrhotic patients who underwent mesocaval interposition shunt surgery because of bleeding esophageal varices was prospectively compared with that of nine matched patients treated with transesophageal sclerotherapy. A further significant increase in methionine and tyrosine serum levels was noted after shunt surgery. It is concluded that sclerotherapy influences serum amino acids less, which might be an advantage in relation to the development of hepatic encephalopathy.

PATTERN OF SERUM BETA-HEXOSAMINIDASE IN LIVER-CIRRHOSIS

The activity of the primarily lysosomal hydrolase, beta-hexosaminidase (EC 3.2.1.30), was studied in serum from 53 patients with bleeding esophageal varices, portal hypertension, and liver cirrhosis (31 alcoholic, 13 cryptogenic, and 9 primary biliary). The serum enzyme activity was determined on 89 occasions and was increased in 93%. There was no difference in the distribution between the three patient groups, but in patients who underwent portal-systemic shunt surgery there was a significant increase after 9-12 months. Serum beta-hexosaminidase activity correlated significantly with other biochemical tests known to be influenced by portal-systemic shunting. It is concluded that determination of this enzyme might become a useful liver test, since it sensitively detects liver disease and also might be specific, since besides liver disease only pregnancy and lysosomal disorders are known to show considerable elevations in serum activity.

Total fasting serum bile acids and β-hexosaminidase in alcoholic liver disease

Total serum bile acid levels and beta-hexosaminidase activity were studied in 22 normal subjects, 35 non-cirrhotic patients with acute alcohol intoxication, 45 patients with alcoholic liver cirrhosis and 11 patients with alcoholic liver cirrhosis and surgical portal-systemic shunts. Comparison was made with traditional liver function tests. beta-Hexosaminidase was most frequently elevated in acute alcohol intoxication (94%) while total serum bile acids were elevated in all patients with alcoholic liver cirrhosis. Total serum bile acid levels were found to discriminate most efficiently between acute alcohol intoxication and liver cirrhosis. The combined determination of serum beta-hexosaminidase and total serum bile acids is proposed for evaluating alcoholic liver disease.

Effect of Vegan and Meat Protein Diets in Mild Chronic Portal-Systemic Encephalopathy

Patients with liver impairment tend to develop protein intolerance, and excess protein intake may in these patients precipitate encephalopathy. The etiology of hepatic encephalopathy is closely linked to the altered protein metabolism in liver disease.1 There is some evidence to suggest that tolerance to protein diets in liver disease may vary depending on the nature of the diet. Fenton et al.2 demonstrated that patients with portal-systemic encephalopathy (PSE) tolerate a milk diet better than a similar amount of protein given as meat. More recently Greenberger et al.3 reported results suggesting that patients with encephalopathy tolerate vegetable protein better than meat protein. There may be several reasons for this difference such as different generation of ammonia and different amino acid profiles in various types of protein.